Goals of Care Conversations Part 1 Reframing Were in a Different Place Training for Physicians Advance Practice Nurses and Physician Assistants Serious Illness Communication Skills Training ID: 763844
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Goals of Care Conversations – Part 1Reframing: We’re in a Different Place Training for Physicians, Advance Practice Nurses, and Physician Assistants
Serious Illness Communication Skills Training Delivering Serious News Conducting Goals of Care Conversations Part 1 - Reframing: We’re in a Different Place Part 2 - Mapping the Future: Clarifying Priorities Part 3 - Aligning with Patient ValuesPart 4 - Discussing Life-Sustaining Treatments
Setting PerceptionI nvitationKnowledgeEmpathize Name Acknowledge “I wish”Summarize/StrategizeReview: Delivering Serious News SPIKES
Since Last Time, Have You Delivered Serious News? What went well? Any challenges?
Goals of Care: What Makes these Conversations Tough? Uncertainty Emotions And … the lack of a framework within which to enter the conversation
What We Will Learn REMAP: A Talking Map for Goals of Care Conversations What We Will Learn
How We Will Learn Define skills (lecture)Observe skills in action (videos) Practice (drills)
Reassess understanding & ReframeExpect emotion Map out what’s importantAlign with patient valuesP lan treatment to match patient values REMAP: Discussing Goals of Care
“Would it be ok if I talk to you about what lies ahead with your illness?” “Today, I wonder if we can talk about how things are going with your medical problems?”REMAP: Introducing the conversation
“What is your understanding of your illness?” If pt has a clear understanding: “Given where you are in your illness, it seems like a good time to talk about where to go from here” REFRAME if pt doesn’t clearly understand the seriousness of their illness: “We’re in a different place than we were [X] months ago.” REMAP: Reassess Understanding and R eframe
Most patients will have an emotional response to hearing the reframe. This is normal. The emotional response may sound like a factual question:“Isn’t there something else you can do?” “Are you sure we’ve looked into everything?”REMAP: E xpect Emotion
Respond to emotion with empathic statements Even if the patient is asking a questionTools for responding to emotion:Name Acknowledge“I wish” R E MAP: Expect Emotion (Responding)
“I can see that you are really concerned” “I get a sense that this is not what you were expecting to hear today” “I wish you weren’t having these kidney problem.” Ask permission before moving on “Is it OK for us to talk about what this means?” REMAP: Expect Emotion (examples)
REMAP: Reframe and Expect Emotion
What specifically did the clinician do that you liked?
Time to Practice!!
Review drill as a group Divide into pairs Practice the drillSwitch rolesDebrief with one another: How did it feel to say the words?One thing you noticed as the clinicianOne thing you noticed as the patient Drill Instructions
Patient Clinician Drill A: R eassess Understanding I’m not getting better with this treatment, but there’s got to be something else out there! Tell me what you understand about your illness. I wish we had a more effective treatment.
I know I’ve got COPD, and I’ve been feeling worse and worse. But I’ve had this for quite a while, and it will probably get better… What’s your sense of where things are? You’ve been living with this disease a long time. And, I think we’re in a different place now. Patient Clinician Drill A: R eframe Drill A: Reframe
What’s your sense of where things are? This must be hard. I hear that. Is it ok if we talk about where we can go from here? Patient Clinician Drill A: E xpect Emotion I know I’m getting worse. I’m afraid I’m just a burden on my kids. It is. There’s a lot happening. Drill A: Expect Emotion
Drill A: Swap Roles Patient Clinician
How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patientDrill A: Debrief
Drill B: Expect Emotion So, what are you saying – that I’m supposed to give up? You’ve been living with this disease a long time. And, I think we’re in a different place now. I can’t even imagine what it’s like for you to live with an illness that keeps getting worse. Patient Clinician
I’m a fighter. I know I can still beat this thing. It’s probably a good time to step back and talk about where we go from here. I really admire your spirit and everything you’ve done to fight this illness. Patient Clinician Drill B: E xpect E motion
I’ve just kept hoping that the treatments would work. I can see how disappointing this is for you. I was hopeful too… Would it be all right if we talked about where we go from here? Patient Clinician Drill B: Moving Forward Drill B: Moving Forward
Patient Clinician Drill B: Swap Roles Drill: Swap Roles
Drill: Debrief Drill B: Debrief How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patient
What surprised you? What do you want to take forward?Anywhere you might get stuck? What’s one thing you will try in the next two weeks? Goals of Care Conversations: REMAP Reassess understanding & Reframe E xpect emotion M ap out what’s important A lign with patient values P lan treatment to match patient values
Goals of Care Conversations Goals of Care Conversations training materials were developed and made available for public use through U.S. Department of Veterans Affairs contracts with VitalTalk[Orders VA777-14-P-0400 and VA777-16-C-0015]. Materials are available for download from VA National Center for Ethics in Health Care atwww.ethics.va.gov/goalsofcaretraining.asp.